Test 2 Flashcards
(106 cards)
1
Q
The 2014 TJC National Patient Safety Goals are to help with what?
A
Are specifically directed at reducing the risk of medical errors.
2
Q
adverse events that should never occur in HC setting
A
Never events
3
Q
Patients who need supplemental O2 in HC settings can be at risk for what?
A
- Strict codes regulate use & storage.
- Smoking around O2 can cause fires, resulting in injuries & death.
- Low concentrations of O2 can cause nausea, dizziness, headache, and fatigue.
- High concentrations are often fatal.
- Carbon monoxide is a colorless, odorless gas. A furnace, stove, or fireplace not properly vented introduces carbon monoxide into environment. Installing carbon monoxide monitor
4
Q
What organisms are common causes of foodborne illness?
A
Escherichia coli, Salmonella, and Listeria
5
Q
Exposure to extreme heat can cause what change to the body?
A
Exposure to extreme heat changes body electrolyte balance and raises core body temp, result in heatstroke or heat exhaustion.
6
Q
According to CDC risk of MVAs are highest in which age group?
A
According to CDC risk of MVAs higher among 16-19-year-old drivers than other age-group .
7
Q
Any substance that impairs health or destroys life when ingested, inhaled, or absorbed by body.
A
Poison
8
Q
What’s a major cause of death and injury?
A
Home fires
9
Q
Leading cause of unintentional deaths for an elder person is?
A
falls in the home leading cause of unintentional death.
10
Q
Physical hazards that lead to falls in home are?
A
inadequate lighting, barriers along normal walking paths & stairs, lack of safety devices.
11
Q
Examples of Man-made disasters are?
A
biological, chemical, radiological attacks.
12
Q
Most common means of transmission of pathogens is by?
A
Hands
13
Q
process by which resistance to infectious disease is produced or increased
A
Immunization
14
Q
What are main types of pollutants?
A
Water, soil, air and noise.
15
Q
School-age child at risk for what?
A
at risk for head injuries resulting from falls, MV injuries, and bicycle injuries (head injuries major cause of death)
16
Q
What age group is especially at risk for injury or death due to automobile accidents, drowning, and substance abuse?
A
Adolescents
17
Q
patient-related physiological conditions (vision
disturbances, urinary/stool frequency or incontinence, mental
impairment, gait & balance disorders, polypharmacy, older age)
A
Intrinsic
18
Q
environmentally related (room clutter, loose electrical cords, and spills)
A
Extrinsic
19
Q
Equipment-related accidents result from what?
A
an electrical hazard or malfunction,
disrepair, or misuse of equipment.
20
Q
What nursing diagnosis should be prioritized?
A
an electrical hazard or malfunction,
disrepair, or misuse of equipment.
21
Q
What can side rails help and hinder?
A
Side rails help increase a patient’s mobility & stability when in bed or moving from bed to chair - shown to increase occurrence of falls when patients attempt to get out of bed & crawl over rail.
22
Q
How do many falls occur in the hospital?
A
Many falls occur as patients try to get out of bed
unassisted.
23
Q
Factors contributing to the patient’s immobility include what?
A
Factors contributing to the patient’s immobility include length of stay, severity of illness, emotional status, and physical condition.
24
Q
The terms body alignment and posture are similar and refer to what?
A
the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying.
25
Body alignment
Body alignment means that the individual’s center of gravity is stable.
26
Damage to any component of the central nervous system that regulates voluntary movement results in what?
impaired body alignment, balance, and mobility. For example, trauma from a head injury.
27
Direct trauma to the musculoskeletal system results in what?
in bruises, contusions, sprains, and fractures.
28
mobilizing it to promote healing and restore function. temporary immobilization results in what?
in some muscle atrophy, loss of muscle tone, and joint stiffness.
29
atelectasis
collapse of alveoli
30
hypostatic pneumonia
inflammation of the lung from stasis or pooling of secretions.
31
What can immobility do to metabolism?
Immobility disrupts normal metabolic functioning, decreasing the metabolic rate.
32
Major shifts in blood volume occur in what patients?
in immobile patients, resulting in diuresis, loss of electrolytes, calcium resorption, and hypercalcemia. The immobile patient is at risk for constipation from lack of activity and hypercalcemia, which depresses peristalsis.
33
A joint contracture
is a preventable, abnormal, and possibly permanent condition characterized by fixation of the joint.
34
a disorder characterized by bone resorption
Disuse osteoporosis
35
for acutely ill patients with restricted activity how often should a respiratory assessment be performed?
Every 2 hours (check Rate and oxygen saturation; Identifies presence of secretions)
36
What are interventions for the respiratory system?
promote expansion of chest and lungs, preventing stasis of pulmonary secretions, and maintaining a patent airway.
37
How do you promote lung expansion?
Promote lung expansion through regular deep-breathing exercises, incentive spirometer, forceful coughing.
38
What foods help normal peristalsis?
A diet rich in fruits and vegetables helps to facilitate normal peristalsis
39
Older adults benefit from what kind of exercise?
Older adults benefit when exercise routines are mildly progressive.
40
What reduces the stasis of pulmonary secretions?
Coughing
41
What do you do if a patient is too weak/ unable to cough up secretions?
Suction
42
After prolonged bed rest what happens to vitals?
usually ↑ heart rate, ↓ pulse pressure, ↓ BP
43
What happens when a patient moves up in bed or strains on defecation?
a Valsalva maneuver occurs – teach to breathe out while moving or being lifted.
44
How often should compression stockings be removed?
Remove and reapply them at least every 8 hours. Elastic stockings help to maintain pressure on muscles of lower extremities and promote venous return.
45
Instruct NAP to inform patient about what information regarding stockings?
avoid activities that promote venous stasis (e.g., crossing legs, wearing garters), elevate legs while sitting and before applying stockings to improve venous return. Not to massage legs. To avoid wrinkles in the stockings. Remove compression stockings at least once per shift.
46
Continuous use of what tools to monitor high-risk patients helps prevent pressure ulcers?
Braden Scale
47
How long should a patient sit uninterrupted in a chair?
Usually the time that a patient sits uninterrupted in a chair is limited to 1 hour. • Teach patients to shift their weight every 15 minutes.
48
How are young old aging adults classified?
Some classify young old as vigorous and active
49
Old old is classified as?
Old-old: frail and infirm
50
For older adults where are placements to avoid for IV insertion?
Avoid placement in areas that are easily bumped (less subcutaneous fat to support placement). Avoid back of hand. Decrease insertion angle to 10-15 degrees (less subcutaneous fat)
Stabilize rolling vein – apply traction to skin below insertion
51
What is a patient at risk for who has a less effective cough?
Increased risk for aspiration, atelectasis, pneumonia.
52
arteriosclerosis
Blood vessels less elastic
53
Decreased salivary secretions
harder to swallow
54
Hypertrophy
The increase in the volume of an organ or tissue due to the enlargement of its component cells.
55
Renin is stored in renal cells
when renal perfusion decreases – released
Activates series of substances that ultimately cause water retention to increase circulating blood volume & causes vasoconstriction
56
When RBC count low (therefore deficiency of O2 in kidney cells), what happens?
kidney releases erythropoietin - stimulates bone marrow to produce RBCs.
57
What are terms that describe process of bladder emptying?
Urination, micturition, voiding
58
What is normal blood capacity?
Normal bladder capacity in adults is approximately 300 to 600 mL.
59
What can increase voiding?
Anxiety and stress may increase voiding.
60
What can decrease desire for urinary continence?
Depression
61
What can obstruct bladder outlet causing urinary retention?
Prostatic enlargement
62
Cystoscopy may cause what?
Cystoscopy may cause localized trauma of urethra resulting in transient (1-2 day) dysuria and hematuria
63
2 continent urinary diversions
- continent urinary reservoir, created from distal portion of ileum and proximal portion of colon.
- ureterostomy, or ileal conduit: permanent incontinent urinary diversion created by transplanting ureters into a closed-off portion of ntestinal ileum and bringing other end out onto abdominal wall forming a stoma.
64
Ileocecal valve
Ileocecal valve creates a one-way valve in pouch, through which catheter is inserted to empty urine from pouch.
65
Nephrostomy tubes
Nephrostomy tubes are small tubes that are tunneled through skin into renal pelvis.
66
Test for a urinary tract infection by?
- What medications patient is taking.
- Bladder scan: determine if she has urinary retention.
- May order intermittent catheterization.
- Recent catheterization, decreased mobility, history of diabetes make more prone to urinary retention, incontinence of small amounts of urine, and urinary tract infection (UTI).
67
How do you expose female genitals?
Female patient will need to lie in the dorsal recumbent position to expose genitalia.
68
Urinary output is a strategic indicator of what?
kidney function and bladder function.
69
Output measurement includes what?
vomitus, gastric drainage tubes, and wound drains.
70
What time of day will urine be most concentrated?
Urine will be more concentrated in the morning.
71
What can change the color of urine?
Medications can change color, as can beets, rhubarb, or blackberries.
Dark amber urine result of bilirubin from liver disease.
Urine may be cloudy with renal disease, bacteria, or WBCs.
72
BUN & Creatinine BOTH elevated with what?
Renal disease
Creatinine best indicator of renal disease.
BUN can be elevated with dehydration.
73
What eases discomfort and induces micturition?
Relaxing in a bath eases discomfort and induces micturition.
74
CAUTI =
catheter-associated urinary tract infection
75
When should a patient void after a catheterization?
Patient should void within 6-8 hours after catheter removed
76
HAUIT (hospital acquired urinary tract infections)
HAUIT (hospital acquired urinary tract infections) - 1 of newer events identified by Centers for Medicare and Medicaid Services (CMS).
77
What does a normal stoma look like?
Stoma normally red & moist - located in right lower quadrant of abdomen.
78
Most commonly used: antimuscarinics
Include darifenacin, oxybutynin, solifenacin, fesoterodine, tolterodine, tropsium.
79
Mirabegron
Mirabegron newer agent that does not have same adverse effects as tantimuscarinics but can cause problems with blood pressure.
80
What happens with severe impaction?
In severe impaction the hardened fecal mass extends up into the sigmoid colon.
81
with bowel elimination what do you need to examine?
You need to conduct an examination of the oral cavity, abdomen, and external anal opening.
82
What is a common test for checking blood in the stool?
A common test is the fecal occult blood test (FOBT), or guaiac test - measures microscopic amounts of blood in feces.
83
What cleanses the bowel for patients undergoing GI tests and abdominal surgery.
Laxatives and cathartics
84
Cathartics
Cathartics stronger and more rapid effect on intestines than laxatives
85
Suppositories
may act more quickly because of their stimulant effect on rectal mucosa.
86
Osmotic
distend the bowel to stimulate peristalsis
87
Stimulant laxatives
increase intestinal motility, inhibit resorption of water in large intestine.
88
Antidiarrheal agents
decrease intestinal muscle tone to slow passage of feces so more water through absorbed through
89
High and low refer to what?
High and low refer to the height and pressure with which you deliver the fluid
High enemas cleans entire colon.
Low enema cleans only rectum and sigmoid colon.
90
The new stoma may be swollen for how long?
The new stoma may be edematous, or swollen, for up to 6 weeks.
91
A nurse discovers an electrical fire in a patient’s room. Which action should the nurse take first?
Evacuate any patients/visitors in immediate danger.
(The first action is to rescue and remove all patients in immediate danger, then activate the alarm, confine the fire, and extinguish the fire.)
92
A nursing team conference is being held to discuss a patient who wanders frequently. The 72-year-old gets lost on the nursing unit and goes into other patients’ rooms. The nursing team selects a set of interventions. Which of the following is not an appropriate restraint alternative?
When the patient becomes aggressive with other patients, confronting her and immediately removing her from the room
(The proper way to deal with aggressive behavior is de-escalation and time-out. Confronting the patient and having her leave the room might increase her aggression.)
93
Which of the following nursing interventions takes priority if the nurse suspects that the patient has a pulmonary embolus?
Checking the patient’s oxygen saturation and vital signs, raising the head of the bed to high Fowler’s unless contraindicated, having someone call the health care provider
You need to know the patient oxygen saturation level and vital signs immediately.
94
Which of the following are physiological outcomes of immobility?
Decreased lung expansion
95
Which of the following symptoms are warning signs of possible colorectal cancer according to American Cancer Society guidelines?
Change in bowel habits, Blood in the stool, A larger-than-normal bowel movement, Muscle cramps
96
A healthy 50-year-old male has a history of prostate disease. Which nursing assessment question best indicates that he is not emptying his bladder completely and has overflow incontinence?
“Do you dribble urine constantly?”
97
A bacteria that is spread through inadequate preparation or storage of food is?
Listeria
98
Characterized by bone resorption
Disuse osteoporosis
99
Ischemia
Temporary decrease in blood supply to an organ or tissue.
100
Permanent plantar flexion
Footdrop
101
Lung inflammation from stasis or pooling of secretions
Hypostatic pneumonia
102
Increased urine excretion
Diuresis
103
Atelectasis
Collapse of aveoli
104
Renal calculi
Calcium stones in the kidney
105
Accumulation of platelets, fibrin, clotting factors, and cellular elements attached to the interior wall of an artery or vein
Thrombus
106
Melena
Blood in the stool
